The Impact of COVID-19 on Dental Nursing – the Forgotten Profession ©FG Trade/Istock/Getty Images Plus Trade/Istock/Getty ©FG

FEATURE

The impact of COVID-19 on dental nursing – The forgotten profession ©FG Trade/iStock/Getty Images Plus Trade/iStock/Getty ©FG

M. Dingle1 and C. Balmer2 conducted a study of 1,006 dental nurses. Thirty-two percent reported difficulty paying their annual retention fee to the GDC and 65% have considered leaving dentistry.

Abstract further afeld. In the UK, the dental profession has faced numerous Introduction Te experiences of the dental nursing profession challenges since the four Chief Dental Ofcers advised the cessation though the COVID-19 pandemic is not well publicised. Aims To of all routine face-to-face dentistry on 25 March 2020.1 Te negative highlight the impact that COVID-19 has had on our dental nursing efect COVID-19 has had on patients’ ability to access urgent care has colleagues. Design A 24-point anonymous online survey created been well documented at national level, with emotive reports such using Microsof Forms, collecting both quantitative and qualitative as a patient extracting his own molar without local anaesthetic being data. Setting A link to the survey was shared on fve popular published on the national BBC news website.2 Te impact COVID- national UK dental nursing Facebook groups, the majority of 19 has had on dentists themselves has also been well publicised with which require a name and associated GDC number to become a the help of the British Dental Association (BDA), with numerous member. Materials and method A link to the survey was shared stories being published in the national press highlighting the fnancial on 21 September 2020 and was open for four weeks. Results: One hardship many dentists are having to endure.3 thousand and six dental nurses completed the questionnaire by Within current publications there is an obvious defcit concerning 22 October 2020. Eight hundred and eighty-eight respondents the experiences of key members of the dental team, our dental work in a dental practice, 65% NHS and 35% private. Seven nurse colleagues. Professor Phil Taylor, Dean of the Royal College percent of respondents have been redeployed whilst 48% of Surgeons of Edinburgh (RCSEd)’s Faculty of Dental Surgery has report being furloughed. Forty-nine percent report COVID- raised concerns about a potential wave of dental nurse jobs being put 19 has had a negative efect on their personal fnances and at risk due to the fnancial uncertainty the pandemic brings. Professor 32% report fnancial difculty paying their GDC registration. Taylor goes on to state that ‘dental nurses play a vital role in the Sixty-fve percent have considered leaving dentistry altogether. dental profession and are an essential part of the team. It is of utmost Discussion Nearly two-thirds of the respondents have importance that they are supported during this period… they need considered leaving the profession, commonly stating stress, better support from the UK Government as well as the NHS as they pay and the General Dental Council (GDC) annual retention adjust to new regulations, PPE and AGP procedures’.4 fee (ARF) as determining factors. Conclusion Dental nurses Triggered by the COVID-19 pandemic, the British Association of are indispensable members of the dental team and it is Dental Nurses (BADN) are currently campaigning for recognition of worrying to see such high levels of dissatisfaction within dental nurses’ contribution to dentistry and have produced a template their profession. letter for members to send to their local MPs.5 BADN President Jacqui Elsden explains the key issue this letter seeks to address: recognition of Introduction NHS employment status - with the associated benefts: access to NHS It is clear that the COVID-19 pandemic has had a huge pension scheme, key worker status and salary banding - refecting the impact on dentistry in both the United Kingdom and fnancial outgoings such as registration fees, indemnity cover, training

1Matthew Dingle BDS, MFDS RCSEd, PGCME, Clinical Lecturer in Oral Surgery, Liverpool University Dental Hospital; 2Miss Colette Balmer BSc (Hons), BChD, FDSRCS (Edin), FDSRCS (Eng),PCTLCP, MA Clin Ed, FHEA, Consultant in Oral Surgery/ Honorary Senior Clinical Lecturer, Liverpool University Dental Hospital

and CPD costs. In addition, the BADN have also lobbied 34 the GDC for a reduction in the annual 56 52 retention fee (ARF) for dental nurses to help Dental Practice ease fnancial pressures, or at least to allow for payment in monthly instalments. However, it Community Dental Service was confrmed at the GDC October Council meeting that the ARF is to be maintained at its current level for the coming year.6 Te BADN Hospital 888 President reports this refusal to recognise the dire fnancial plight of the largest registrant Other group, insisting on full payment of £114 by 31 July, has led to more than 3,500 dental nurses failing to re-register.5 Fig. 1 Responses to Q1: Where do you work? Materials and methods: A 24-point anonymous survey was created using Microsof Forms. Questions 1-22 are closed questions allowing for quantitative data 55 15 capture. Q23 – ‘If you have considered leaving Extremely confident dentistry altogether, please explain why’ and Q24 – ‘Do you have any other comments Confident 255 regarding the impact of COVID-19 on the 188 nursing profession?’ gave the opportunity for Neither confident or unconfident participants to express their concerns in their own words, providing qualitative data for Unconfident 493 analysis. Q23 and Q24 were then subject to thematic analysis to identify key trends. Extremely unconfident On 21 September 2020 a link to the online survey was shared on fve popular national dental nurses Facebook groups: Advice for Dental Nurses, Dental Nurse Support, Dental Fig. 2 Responses to Q8: To what extent are you confdent following new COVID-19 SOPs in your workplace? Nurse (UK), Support for Dental Nurses (UK), Northwest Dental Nurse Forum. Most Facebook groups are closed groups, ofen is it predominantly NHS or private? procedures are classed as AGPs? requiring full name and GDC registration Of the 86% (888 participants), 65% work in an Ninety-eight percent (985 participants) know number for the administration staf to grant NHS dental practice and 35% work in private what dental procedures are classed as AGPs. entry, although it is acknowledged there are practice. a number of members who are non-GDC Q7: To what extent has COVID-19 registered trainees. Permission to post the Q3: Have you worked in an Urgent changed your working practice? survey link to was granted by the group Dental Centre (UDC) during the Ninety percent (906 participants) report administrator on each occasion. Te link was COVID-19 pandemic? COVID-19 has signifcantly changed their posted by a registered dental nurse colleague at Eighty percent of respondents report they have working practice. Nine percent report COVID- Liverpool University Dental Hospital. not worked in an Urgent Dental Centre during 19 has slightly changed their working practice. the pandemic. Four participants reported their working Results practice has not changed at all. A total of 1,006 dental nurses completed the Q4: Have you been redeployed survey by 22 October 2020. One thousand and during the COVID-19 pandemic? Q8: To what extent are you confdent two of these responses were recorded between Ninety-three percent (931 participants) report following new COVID-19 Standard 21 September – 1 October 2020. that they have not been redeployed during Operating Procedures (SOPs) in your the pandemic; 7% (75 participants) have been workplace? Q1: Where do you work? Please tick redeployed. Te responses to Q8 are illustrated in Figure 2. all that apply. Twenty-fve percent (255 participants) feel Te responses to Q1 are illustrated in Figure 1. Q5: Are you undertaking Aerosol extremely confdent following new COVID-19 Eighty-six percent of participants work Generating Procedures (AGPs) at Standard Operating Procedures (SOPs); 49% in dental practice. Five percent work in the your place of work? (493 participants) feel confdent. Terefore, community dental service and 5% work in a Ninety-four percent of participants are a total of 74% feel confdent or extremely hospital. Tree percent work in ‘other’ which undertaking AGPs at their place of work; 6% confdent following new COVID-19 SOPs. includes: MOD, HMP, Locum, 111, EDS. (60 participants) are not undertaking AGPs. Only 1% feel extremely unconfdent and only 5% feel unconfdent. Nineteen percent feel Q2: If you work in a dental practice, Q6: Do you know what dental neither confdent nor unconfdent. www.nature.com/BDJTeam BDJ Team 15 © 2021 British Dental Association. All rights reserved. FEATURE

Q9: To what extent do you feel safe following the new COVID-19 21 Standard Operating Procedures Very safe (SOPs) in your workplace? 78 Te responses to Q9 are illustrated in Figure 3. 196 Safe Nineteen percent (196 participants) feel very safe following new COVID-19 SOPs. 254 Neither safe nor unsafe Forty-fve percent (457 participants) feel safe. Terefore, 64% feel safe or very safe 457 following new COVID-19 SOPs. Eight percent Unsafe (78 participants) feel unsafe, and 2% (21 participants) feel very unsafe. Twenty-fve Very unsafe percent (254 participants) feel neither safe nor unsafe. Fig. 3 Responses to Q9: To what extent do you feel safe following the new COVID-19 SOPs in your workplace? Q10: I have received adequate training and support in implementing/undertaking these SOPs. 32 Te responses to Q10 are illustrated in Figure Strongly agree 4. Twenty-one percent (209 participants) 126 Agree 209 strongly agree that they have received adequate training and support implementing/ Neutral undertaking these SOPs. Tirty-seven percent 264 (375 participants) agree they have received 375 adequate training. Terefore, a total of 58% Disagree of participants agree or strongly agree they have received adequate training. Twenty-six Strongly disagree percent (264 participants) are neutral. Tirteen percent (126 participants) disagree and 3% (32 participants) strongly disagree. Fig. 4 Responses to Q10: I have received adequate training and support in implementing/undertaking these SOPs

Q11: I have been ft tested for an FFP2/FFP3 face mask to perform AGPs. Eighty-nine percent (897 participants) Strongly agree have been ft tested for an FFP2/FFP3 mask to 73 178 perform AGPs. Ten percent (104 participants) Agree have not been ft tested and 1% (fve 187 participants) are not sure. Neutral 330 Q12: I am anxious about wearing Disagree 238 enhanced PPE. Te responses to Q12 are illustrated in Figure Strongly disagree 5. Eighteen percent (178 participants) strongly agree that they are anxious about wearing enhanced PPE. Tirty-three percent (330) Fig. 5 Responses to Q12: I am anxious about wearing enhanced PPE agree that they are anxious about wearing enhanced PPE. Twenty-three percent (238 participants) are neutral, whilst 19% (187 participants) and 7% (73 participants) disagree Twenty-three percent (235 participants) Eleven percent (110 participants) disagree and and strongly disagree respectively that they are strongly agree they are comfortable being close 3% (28 participants) strongly disagree with this anxious wearing enhanced PPE. to patients and staf provided they are wearing statement. the appropriate PPE. Forty-fve percent Q13: I am comfortable being close (455 participants) agree with this statement. Q14: Have you been furloughed? to patients and staff provided I am Terefore, 68%, over two-thirds, of participants Fify-two percent (518 participants) have not wearing the appropriate PPE. are comfortable being close to patients and staf been furloughed, whilst 48% (483 participants) Te responses to Q13 are illustrated in Figure provided they are wearing the appropriate PPE. have been furloughed. 6. Eighteen percent (178 participants) are neutral.

as a result of COVID-19, whilst 32% (326 28 participants) report a decrease in their total Strongly agree weekly hours as a result of the pandemic. 110 Tirty-three percent (330 participants) did not Agree 235 answer. 178 Neutral Q17: Has COVID-19 had a negative impact on your personal fnances? Forty-nine percent (488 participants) report Disagree 455 COVID-19 has had a negative efect on their personal fnances, 46% (461 participants) Strongly disagree state COVID-19 has not had a negative efect on their personal fnances, whilst 5% (52 participants) are not sure. Fig. 6 Responses to Q13: I am comfortable being close to patients and staff provided I am wearing the appropriate PPE Q18: As a result of COVID-19 have you encountered fnancial diffculty paying your GDC registration? Tirty-two percent (322 participants) report they have encountered fnancial difculty Weekends 95 paying their GDC registration. Sixty-eight percent (675 participants) report they have not 148 Late nights encountered fnancial difculty paying their 642 GDC registration. Both 121 Q19: I am happy with the support my employer has given me during Neither the COVID pandemic. Te responses to Q19 are illustrated in Figure 8. Twenty-one percent (208 participants) Fig. 7 Responses to Q15: Have you worked weekends or late nights due to COVID-19? are extremely happy with the support their employer has given them during the pandemic. Tirty-two percent (323 participants) are happy whilst 28% (275 participants) are neither 60 happy nor unhappy. Fourteen percent (140 Extremely happy participants) and 6% (60 participants) are unhappy and extremely unhappy respectively. 208 Happy 140 Terefore, one in fve participants are either unhappy or extremely unhappy with the Neither happy or unhappy support their employer has given them during the pandemic. 275 323 Unhappy Q20: If applicable, has your employer been fexible regarding Extremely unhappy childcare during the COVID-19 pandemic? Te responses to Q20 are illustrated in Figure Fig. 8 Responses to Q19: I am happy with the support my employer has given me during the COVID-19 pandemic 9. Ninety-eight participants report their employer has been extremely fexible regarding childcare during the pandemic, whilst 155 Q15: Have you worked weekends or worked late nights. 12% (121 participants) have participants report their employer has been late nights due to COVID-19? worked both additional weekends and late fexible. Eighty-fve participants are unsure. Te responses to Q15 are illustrated in Figure nights as a result of COVID-19. Sixty-three participants state their employer 7. has been infexible with regards to childcare Sixty-four percent (642 participants) Q16: If your total number of hours whilst 32 participants state their employer has reported working no additional late nights or per week has changed, have they been very infexible. Tis question was not weekend work due to COVID-19. Nine percent increased or decreased? applicable to 573 participants. (95 participants) have worked additional Tirty-fve percent (350 participants) report weekends whilst 15% (148 participants) have their total weekly hours have increased www.nature.com/BDJTeam BDJ Team 17 © 2021 British Dental Association. All rights reserved. FEATURE

Q21: What effect has COVID-19 had on your mental health? 600 Te responses to Q21 are illustrated in Figure Very flexible 10. 573 500 Fify-three percent (530 participants) report Flexible COVID-19 has had a negative impact on their 400 mental health, whilst 13% (135 participants) Unsure report it has had an extremely negative efect. 300 Terefore, two-thirds (66% of participants) Inflexible report COVID-19 has had a negative or 200 extremely negative impact on their mental Very inflexible health. Twenty-eight percent (282 participants) 100 155 98 32 report COVID-19 has had no efect on their Not applicable 85 63 mental health. Tree percent (31 participants) 0 report the pandemic has had a positive efect on their mental health, whilst 0.9% (nine participants) report an extremely positive efect. Fig. 9 Responses to Q20: If applicable, has your employer been fexible regarding childcare during the COVID-19 pandemic?

Q22: Has the COVID-19 pandemic made you consider leaving dentistry altogether? 600 Sixty-fve percent (655 participants) report Extremely postive the COVID-19 pandemic has made them 500 530 consider leaving dentistry altogether. Tirty- Positive fve percent (351 participants) report they have 400 not considered leaving dentistry as a result of No eﬀect the pandemic. 300 Negative 282 Q23: If you have considered quitting, 200 why? Extremely negative 100 135 Of the 655 participants who reported they have 19 9 31 considered leaving the profession, thematic Other analysis highlights the reasons shown in Table 1. 0

Q24: Any other comments? Tematic analysis of ‘other comments’ Fig. 10 Responses to Q21: What effect has COVID-19 had on your mental health? highlighted the themes shown in Table 2.

Discussion signifcant period this is not unsurprising, given Table 1 Reasons participants might It is clear that COVID-19 has had a signifcant that as of 20 September 2020 approximately 9.6 leave the profession (Q23) impact on the dental profession in the UK. million jobs from 1.2 million diferent employers Dental nurses, regardless of their place of were furloughed.7 Over one-third of participants Reasons for leaving work, are on the front line and are essential to (36%) have worked additional weekends, the delivery of COVID-19 safe dentistry. It is late-nights, or a combination of both due to GDC/ARF 50 reassuring that only 3% of participants strongly COVID-19. In addition, 35% of participants Pay/wages 184 disagree that they have received adequate report an increase in the total number of hours training and support in implementing COVID- worked per week. Tis highlights the versatility, PPE 80 19 SOPs in their workplace, and only 1% of fexibility and commitment of our dental nurse Health 26 nurses felt extremely unconfdent following colleagues. Tis is invaluable, as without their these SOPs. One in fve nurses are unhappy to presence these additional clinics would not be Pension 11 some degree with the support their employer appropriately stafed and may not be viable at all. has given them during the pandemic. Whilst Two-thirds (66%) of participants report Stress/anxiety 93 this is arguably high, it should be noted that COVID-19 has had a negative or extremely Pressure 80 four in fve nurses are not unhappy with the negative efect on their mental health. Tis employer support they have received. Tis cannot be dismissed as a reason for dental Forgotten 28 suggests that COVID-19-specifc clinical nurses to seek change and leave the profession. training and support by employers has generally Te Society of British Dental Nurses (SBDN) Not/under appreciated 50 been good. are aware of the importance of mental health Glorifed cleaner 10 Nearly 50% of participants have been on their members and as such are part of the 8 furloughed at some point during the pandemic. Mental Health and Wellbeing UK initiative. TOTAL 612 (n = 655) With face-to-face dentistry ceasing for a With such a high number of respondents

Table 2 Thematic analysis of ‘other Conclusion Leading dental professor warns of potential comments’ (Q24) Tis pandemic has been a catalyst for the dental nurse redundancies. 20 October BADN’s campaign to recognise dental nurses’ 2020. Available at: https://www.badn.org.uk/ Other comments contribution to dentistry and highlights the News/Leading-dental-professor-warns-of- issues within the profession. Te long-standing potential-dental-nurse-redundancies.aspx No 634 matter of being recognised as an NHS member (accessed 2 November 2020). Overworked 5 of staf has been thrown into stark relief by 5. British Association of Dental Nurses. COVID-19. Dental nurses have been unable to BADN calls for recognition of dental nurses’ Underpaid 35 access the benefts an NHS key worker brings, contribution to dentistry. 20 October 2020. such as early morning supermarket shopping Available at: https://www.badn.org.uk/News/ Low morale 4 and countless discounts/ofers for NHS staf. BADN-calls-for-recognition-of-Dental- Pay 87 In spite of this, Jacqui Elsden reports that when Nurses--contribution-to-dentistry.aspx the NHS called for volunteers to assist on the (accessed 2 November 2020). Stress 35 front line, dental nurses to her understanding, 6. Moyes W. October post – Council update. were the largest group to volunteer.5 General Dental Council, 26 October 2020. Stressful 23 Mental health 12 ‘It is clear that as a profession dental Pensions 9

GDC 32 nurses are incredibly adaptable, resilient ARF 1 and selfess. The issues raised in this Underappreciated 31

No recognition 33 paper, such as mental health, pay, ARF PPE 36 and NHS worker status have been Furlough 13

Lack of support 53 simmering along prior to COVID-19.’

Lack of guidance 13 It is clear that as a profession dental nurses Available at: https://www.gdc-uk.org/news- Extra workload 32 are incredibly adaptable, resilient and selfess. blogs/blog/detail/blogs/2020/10/26/october- Te issues raised in this paper, such as mental post-council-update (accessed 2 November TOTAL 1,088 (n = 1,006) health, pay, ARF and NHS worker status have 2020). been simmering along prior to COVID-19. 7. Statista. Number of jobs furloughed under reporting an adverse efect on their mental Te pandemic has brought them to the boil, the job retention scheme in the UK 2020. health, it is encouraging that the SBDN are and as a consequence two-thirds of nurses 15 October 2020. Available at: https://www. aware of the issue and have resources in place to involved in this survey are considering quitting statista.com/statistics/1116638/uk-number- support their members. dentistry altogether. As of 31 December 2019, of-people-on-furlough/#statisticContainer Sadly, nearly half of respondents (49%) there were 58,898 registered dental nurses, (accessed 3 November 2020). report COVID-19 has had a negative efect on making up 49% of all titles registered with the 8. Society of British Dental Nurses. Looking their personal fnances and consequently, nearly GDC.6 More than 3,500 have already failed to Back 2020. Te State of Dental Nursing in one-third (32%) have encountered fnancial re-register and our research shows this may the UK. 21 December 2020. Available at: difculty paying their GDC registration. Of the increase signifcantly by July 2021. https://sbdn.org.uk/sbdn/looking-back-the- 652 participants that report considering quitting state-of-dental-nursing-2020/ (accessed 28 dental nursing, over one-third (36%) cite low References December 2020). pay/wages and the GDC’s ARF as the cause. It 1. Hurley S, Neligan M. Preparedness letter for 9. PayScale. Average Dental Nurse Hourly is worth noting that the average hourly rate for primary dental care – 25 March 2020. NHS Pay in United Kingdom. Available at: a dental nurse in the UK is £9.03 per hour.9 Te England and NHS Improvement, 2020. https://www.payscale.com/research/UK/ national living wage (NLW) as of April 2020 is 2. BBC News. Coronavirus: man refused Job=Dental_Nurse/Hourly_Rate (accessed 3 £8.72 per hour.10 Te diference of 31p per hour appointment pulls out tooth at home. 18 November 2020). is almost negligible when considering the GDC’s April 2020. Available at: https://www.bbc. 10. Low Pay Commission. Research and annual retention fee, which is set at £114. As co.uk/news/uk-england-devon-52321910 Analysis. Te National Minimum Wage an example, a full time (40h p/w) dental nurse (accessed 30 October 2020). in 2020. 1 April 2020. Available at: https:// on the national average £9.03p/h would have to 3. BDA. Speaking up for the profession. www.gov.uk/government/publications/the- work over nine full weeks just to ofset the ARF Available at: https://bda.org/ national-minimum-wage-in-2020 (accessed and break even with someone on the (NLW) makingadiference (accessed 30 October 3 November 2020). working equivalent hours (£114/31p = 368 2020). hours. 368h/40h = 9.2 weeks). 4. British Association of Dental Nurses. https://doi.org/10.1038/s41407-021-0555-6 www.nature.com/BDJTeam BDJ Team 19 © 2021 British Dental Association. All rights reserved.